Matters of the Mind: drawing the line between mental illness and normal human emotion in the DSM-5

The Conversation recently ran a ten-part series examining the clinician’s bible for diagnosing mental disorders, the DSM, and the controversy surrounding the forthcoming fifth edition.

Paul Fitzgerald, Professor of Psychiatry at Alfred Health and Monash University, kicked off the series with an explainer on what the DSM is and how mental disorders are diagnosed:

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is a publication of the American Psychiatric Association. It was originally published in 1952 to provide a standardised means for making and coding psychiatric diagnoses.

The DSM is currently undergoing its fifth revision, planning for which has been underway since 1999. This process has generated world-wide debate which has escalated as we approach its publication date. The DSM-5 is due to hit psychiatrists’ shelves in May 2013.

Hans Pols, Associate Professor, History and Philosophy of Science at the University of Sydney, charted psychiatry’s move away from talking therapies to pharmacotherapy:

You’re feeling down. But do you have a low mood because you’re dealing with the loss of a loved one, a break-up or divorce, or abusive co-workers? Or are you suffering from a depressive disorder: a recognised mental illness caused by an imbalance in the neurotransmitters in the brain, for which a variety of effective medical treatments are available?

Modern psychiatry no longer views our low moods as misguided reactions to life’s challenges. Instead, negative emotions are seen as biomedical problems which often require a prescription. This fundamental change in psychiatry occurred in the 1980s, when we shifted from the second to the third edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association (the DSM).

Dominic Murphy, Director for the Unit of History and Philosophy of Science at the University of Sydney, looked at cultural variations in mental illness and the need to take cultural differences into account:

There’s an old saying that psychology has two model organisms: the rat and the American college student. As research subjects rats are fine, the problem is that that Americans are, as evolutionary psychologist Joe Henrich and his colleagues recently pointed out, WEIRD. That is, they’re Western, Educated, Industrialised, Rich and Democratic. In fact, most westerners are WEIRD, but Americans are the WEIRDest of all.

People in western countries have values and minds that are not like those of the rest of humanity. These differences should not be overstated, but they are real, and they have implications for the cognitive sciences that we are only just beginning to explore.

Trichotillomania is a psychological disorder where individuals feel the urge to remove their bodily hair, to the point of obvious hair loss.

While the general community remains largely unaware of the condition, psychiatric cases date back to 1889, when the French physician Francois Hallopeau described a male patient who “manically” pulled out his scalp hair, resulting in bald patches.

Michael Kyrios, Professor of Clinical Psychology & Director, Brain & Psychological Sciences Research Centre at Swinburne University of Technology, examined why the DSM-5 will categorise hoarding as a separate diagnosis:

We’ve all got boxes of old letters, clothes and other keepsakes we’ve collected over our lifetime. Sometimes these boxes or shelves seem to take over spare rooms and garages. But while we might joke that we’re “a bit of a hoarder”, there’s a big difference between holding onto important mementos and compulsive hoarding.

Hoarding is the persistent difficulty discarding or parting with possessions and their ultimate stockpiling – regardless of their value. Possessions may include objects or animals, with the resulting clutter rendering living spaces unusable, unsafe or unhygienic.

Peter Parry, Child and Adolescent Psychiatrist and Senior Lecturer at the University of Queensland, looked at the confusion around labeling mental disorders in children and teenagers:

As a child and adolescent psychiatrist my daily work involves diagnosing children and young people with various mental disorders. There are diagnostic manuals to guide me: the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and the mental disorders section of the the International Classification of Diseases of the World Health Organisation, 10th Edition (ICD-10).

These manuals give algorithms and criteria by which diagnoses can be made. Since its third edition in 1980, the DSM has mostly followed the “medical model” of diagnosing by checking off lists of symptoms with little reference to past or present life stressors or the person’s coping or personality style. And ICD-10 followed the same post-DSM-III model.

Jon Brock, ARC Research Fellow in Cognitive Science at Macquarie University, discussed the controversy surrounding the DSM-5’s redefinition of autism:

For autistic people and their families, getting an autism diagnosis is just the first step in a long struggle to access much-needed intervention, support, and appropriate education.

In Australia, as in many countries, autism diagnoses are made according to criteria laid out in the Diagnostic and Statistical Manual of Mental Disorders (DSM). The latest update to the manual, the DSM-5, is due for publication in May 2013 and will bring significant changes to the definition and diagnosis of autism.

These changes reflect a continually evolving understanding of autism, as well as a desire to make autism diagnosis simpler and more reliable.

Andrew Kemp, NHRC Career Development Fellow at the University of Sydney and Andre Brunoni, Psychiatrist and researcher at the University of Sao Paulo, outlined the controversies around pharmaceutical companies, depression and prescribing:

In Australia, antidepressant medications account for 61% (13.7 million) of all mental health-related subsidised prescriptions, followed by anxiety-reducing medicines. One in five Australians aged 16 to 85 are afflicted by either a mood, anxiety or substance-use disorder.

We now know that depression is not just a disorder of the mind; it also increases risk for a host of conditions and diseases, and mortality. Hence the need for effective treatments.

Richard Bryant, Professor and Director of Traumatic Stress Clinic at the University of New South Wales, looked at the inclusion of prolonged grief as a mental disorder in the DMS-5:

Grief is one of the most universal and distressing experiences that humans suffer.

For most people, the emotional pain of losing someone close to them lasts for a relatively brief period. Many studies indicate that by six months after bereavement, most people begin to experience remission of the severe grief response. Waves of grief may come and go for months or years afterwards but these reactions don’t impair or limit a person’s capacity to engage in life’s activities.

In contrast, a proportion of bereaved people (approximately 10% to 15%) suffer persistent grief that can last for many years. Many studies from different countries and cultural settings have documented that severe yearning for the deceased that persists beyond six months is associated with marked impairment and difficulty in engaging with people and in activities.

Gemma Lucy Smart, MSc Candidate and Dominic Murphy, Director of the Unit for History and Philosophy of Science at the University of Sydney, explained why the DSM-5 will reintroduced the term ‘addiction’ after its absence from the current edition:

The term “addiction” is conspicuously absent from the pages of the current Diagnostic and Statistical Manual of Mental Disorders, the DSM-IV. That’s because in the 1980s, the committee working on the DSM-III-R were keen to avoid the cultural baggage and stigma associated with the word addiction. They hoped to provide more neutral and clinically useful terms by using “dependence” and “abuse” in the current category substance-related disorders.

Experience proved this to be a mistake – the terms were confusing and misleading.

About this blog

The Croakey blog is a forum for debate and discussion about health issues and policy. It is moderated by Melissa Sweet, a freelance journalist with a personal and professional bent towards public health perspectives. Regular contributors include members of the Crikey Health and Medical Panel.